Learning From Countries on Measuring and Defining Community-Based Resilience in Health Systems: Voices From Nepal, Sierra Leone, Liberia, and Ethiopia

Abstract

Background: The best approach for defining and measuring community health care resilience in times of crisis remains elusive. We aimed to synthesise definitions and indicators of resilience from countries who had recently undergone shocks (i.e., outbreaks and natural disasters). Methods: We purposively selected four countries that had recently or were currently experiencing a shock: Nepal, Ethiopia, Sierra Leone, and Liberia. Focus group discussions and key informant interviews were conducted with participants at the community, facility, district, sub-national, national, and international levels. Interviews and discussions were translated and transcribed verbatim. Data were open coded in ATLAS.ti using a grounded theory approach and were thematically collated to a pre-specified framework. Results: A total of 486 people participated in the study (n=378 community members, n=108 non-community members). Emergent themes defining community-based health system resilience included: the importance of communities, health system characteristics, learning from shocks, preventing and preparing for shocks, and considerations for sustainability and intersectoral engagement. Participants identified 193 potential indicators for measuring resilience, which fell into the domains of: 1) preparedness, 2) response and recovery, 3) communities, 4) health systems, and 5) intersectoral engagement. Conclusion: Despite varying definitions and understanding of the concept of resilience, community-centred responses to shocks were key in building resilience. Further insight is needed into how the definitions and indicators identified in this study compare to other shocks and contexts and can be used to further our understanding of health system resilience. Metrics and definitions could assist policy makers, researchers, and practitioners in evaluating the readiness of systems to respond to shocks and to allow comparability across health systems. We must build health systems that can continue to function and ensure quality, equity, community-focused care, and engagement, regardless of the pressures put upon them and ensure they are linked to strong primary health care.